Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition Page 2
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Form 8843 (2016)
Page
Part IV
Professional Athletes
15
Enter the name of the charitable sports event(s) in the United States in which you competed during 2016 and the dates of
competition
▶
16
Enter the name(s) and employer identification number(s) of the charitable organization(s) that benefited from the sports
event(s)
▶
Note: You must attach a statement to verify that all of the net proceeds of the sports event(s) were contributed to the charitable
organization(s) listed on line 16.
Part V
Individuals With a Medical Condition or Medical Problem
17a Describe the medical condition or medical problem that prevented you from leaving the United States
▶
b Enter the date you intended to leave the United States prior to the onset of the medical condition or medical problem described
on line 17a
▶
c Enter the date you actually left the United States
▶
18
Physician’s Statement:
I certify that
Name of taxpayer
was unable to leave the United States on the date shown on line 17b because of the medical condition or medical problem
described on line 17a and there was no indication that his or her condition or problem was preexisting.
Name of physician or other medical official
Physician’s or other medical official’s address and telephone number
Physician’s or other medical official’s signature
Date
Sign here
Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and, to the best of my knowledge and belief,
only if you
they are true, correct, and complete.
are filing
this form by
itself and
not with
your tax
return
Your signature
Date
8843
Form
(2016)
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